Co-Director, William Carey University College of Osteopathic Medicine
When the spinal Manifestations of Spinal Cord Injury cord is injured spasms in throat purchase skelaxin 400mg free shipping, transmission of impulses between the brain and other parts of the Symptoms of spinal cord injury specif- body below the level of injury are inter- ically reflect the level of the injury and Conditions Affecting the Spinal Cord 77 C1 C2 C3 C4 Cervical Nerves C6 C7 C8 T1 T2 T3 T4 T5 T6 Thoracic T7 T8 Nerves T9 T10 T11 T12 L1 L2 L3 Lumbar Nerves L4 L5 S1 S2 Sacral S3 S4 Nerves S5 C1 Coccygeal Nerve Figure 3–1 Spinal Nerves muscle relaxant reversal drugs purchase 400mg skelaxin free shipping. If spinal nerves are unable to tracts are injured muscle relaxant pregnancy safe skelaxin 400mg cheap, as with complete sever- transmit messages between the central ance of the spinal cord, both motor loss nervous system and the peripheral nerv- and sensory loss occur below that level. The degree of regardless of the level of injury, with the functional loss is dependent on the degree exception of injury at the sacral level (S-2 to which the spinal cord is injured. For through S-4), in which ambulation may example, if the afferent nerve roots in the return to normal. Individuals with spinal ascending tracts (sensory tracts) are injured, cord injuries above T-12 usually require a some sensory loss below the level of in- wheelchair for ambulation. If efferent nerve roots in the els of injury, ambulation for short dis- descending (motor tracts) are injured, some tances may be possible with braces or motor loss below the level of injury is crutches. Most individuals with of bladder and bowel function after spinal spinal cord injuries at C-4 or above must cord injury. Bladder evacuation may be have an attendant for personal care, accomplished through external collection dressing, and transfers. Individuals may catheters are still used in some instances be able to hold a light object between the for both men and women, although be- thumb and finger, or they may be able to cause of the risk of urinary tract infection, maneuver small objects with the assis- this practice is becoming less common. Assistance will still When feasible, intermittent catheterization be required for most activities; however, several times a day is recommended. In individuals may be capable of transfer on lower-level injuries, such as at the lumbar their own with the assistance of special level, bladder evacuation may be accom- equipment. Total independent living is plished by applying external pressure to probably not feasible, but independent the lower abdomen. Bowel management electrical wheelchair ambulation may be may be accomplished through the use of possible. Individuals with injury at C-6 suppositories or rectal stimulation; how- also have gross motor movement of upper ever, the individual may still be con- extremities and may be able to retain cerned about involuntary bowel move- some independence in self-care, such as ments in public. Propelling a Spinal Cord Injuries at the Cervical Level wheelchair manually may be possible (C-1 through C-8) with a modified hand rim, although many individuals continue to operate a Diving accidents, motor vehicle acci- motorized chair. With the use of hand dents, or a blow to the head with a heavy splints, individuals may also be able to object may cause fractures of the cervical write. An injury to the spinal cord at chair or to a car may also be possible, as the cervical level (C-1 through C-8) results well as driving with the use of special in quadriplegia (paralysis of both upper adaptive devices. Injuries at C-1 or Individuals with C-7 injuries are capa- C-2 are often fatal because the function- ble of straightening their arm and are able ing of all muscles, including the muscles to sit up in bed, dress themselves, and of respiration, is lost. Individuals who sur- transfer, so almost total independence with vive these injuries require ventilatory some adaptations in the environment support in order to breathe and are total- may be achieved. Indi- of the hands are impaired, but writing viduals with injuries at C-3 or C-4 also may be possible with the use of a special have compromised ventilatory capacity device that can be strapped to the hand. Conditions Affecting the Spinal Cord 79 Spinal Cord Injuries at the Thoracic Level function may still be impaired to some (T-1 through T-12) degree. Spinal cord injuries occurring at T-1 or below result in paraplegia (paralysis of Treatment and Management of the lower extremities). Upper extremities, Spinal Cord Injury for the most part, are unimpaired, with Initial Treatment of Spinal Cord Injury the exception of T-1 injuries, in which there may be slight weakness and some The initial treatment of spinal cord in- loss of flexibility in the hands.
The diagnostic value of the erythrocyte sedimentation rate (ESR) and dipstick as an example muscle relaxants yahoo answers order skelaxin 400mg online. Publications on diagnostic test evaluation in family medicine journals: an optimal search strategy back spasms 20 weeks pregnant skelaxin 400mg cheap. Estimating diagnostic accuracy from multiple conflicting reports: a new meta-analytic method muscle relaxant cyclobenzaprine dosage buy genuine skelaxin line. A meta-analytic method for summarising diagnostic test performances: receiver-operating-characteristic-summary point estimates. Combining independent studies of a diagnostic test into a summary ROC curve: data-analytic approaches and some additional considerations. Issues in combining independent estimates of the sensitivity and specificity of a diagnostic test. Analysis and interpretation of treatment effects in subgroups of patients in randomised clinical trials. Heterogeneity in meta-analysis of data from epidemiologic studies: a commentary. Which factors affect the accuracy of the urine dipstick for the detection of bacteriuria or urinary tract infections? The test of Lasègue: systematic review of the accuracy in diagnosing herniated discs. Method guidelines for systematic reviews in the Cochrane Collaboration Back Review Group for spinal disorders. Selecting the language of the publications included in a meta-analysis: is there a Tower of Babel bias? Diagnostic value of the CAGE questionnaire in screening for alcohol abuse and alcohol dependence: a meta-analysis. The diagnostic value of macroscopic haematuria in diagnosing urological cancers. A note on graphical presentation of estimated odds ratios from several clinical trials. Invited commentary: a critical look at some popular meta-analytic methods. Appendix: statistical formulae Pooling of proportions Homogeneous sensitivity and/or specificity For example, for the sensitivity: k Sensitivitypooled a ai> a (ai ci) i 1 where a true positives, c false negatives, i study number, and, k total number of studies, with standard error: p(1 p) SE B n where p sensitivitypooled, and k n a (ai ci) i 1 Cut-off point effect: SROC curve Basic meta-regression formula: ln(DOR)pooled a bS where intercept, regression coefficient, and sensitivity (1 specificity) S estimate of cut-off point lnc d 1nc d (1 sensitivity) specificity With standard error: 1 1 1 1 SEln(DOR) Ba b c d Pooling of likelihood ratios ND log(LR)pooled logc d a bx ND where LR likelihood ratio ND log c d correction factor ND log(number non-diseased/number diseased) i ntercept in logistic regression, regression coefficient, and x test measurement. When workers and researchers in that domain begin to appreciate the potential of ICT, this initial stage is followed by more fundamental changes in that domain that take advantage of the potential of ICT. The explicit purpose of automating medical records is to use the data in those records to support not only the care of individual patients, but also applications such as decision support, quality control, cost control, or epidemiology. First, data recorded on computer can readily be retrieved and reused for a variety of purposes. Second, once data are available on computer, they can easily be transported. Third, as clinicians (and patients) are using computers to record medical data, the same electronic record can be used to introduce other computer programs that interact with the user. Thus the experience in developing decision support systems and analysing observational databases feeds back into the requirements for electronic medical records. Paper as a medium to record data limits our ability to exploit that potential. Electronic medical records will facilitate research that relies on data recorded in routine medical practice. The potential of ICT, however, lies in its ability to close the loop between clinical practice, research, and education.
Many factors contribute to an individ- Psychosocial variables may also compli- ual’s adaptation or adjustment to the so- cate functional capacity and spasms knee cheap 400 mg skelaxin amex, thus spasms in 7 month old skelaxin 400 mg with visa, the cial limitations associated with a partic- rehabilitation process muscle relaxant cephalon buy 400 mg skelaxin with amex. Individuals’ per- uals with chronic illness or disability may ception or misperception of the reactions continue to perform the same work they of others in social groups may determine performed before the onset of the condi- the level of acceptance that they receive. At other times, certain work tasks, The degree to which they are able to environmental conditions, or work sched- adapt, accept, and adjust to their function- ules must be modified to accommodate al limitations is determined in part by the limitations imposed by the chronic ill- 22 CHAPTER 1 PSYCHOSOCIAL AND FUNCTIONAL ASPECTS OF CHRONIC ILLNESS AND DISABILITY ness or disability. If modifications cannot and attitudinal factors, as well as on the be made in these cases, individuals must physical aspects of the illness or disabili- change employment. Accurately assessing individuals’ capac- must assume disability status because ity to return to work consists of more than appropriate modifications cannot be made evaluating physical factors. Job fear of reinjury, vocational dissatisfaction, stress or the attitudes of employers or or legal issues can also hamper return to coworkers can significantly interfere with work. Their ability to relate to and inter- individuals’ ability to return to the work act with others within the work environ- force. Interests, from work because of limitations caused aptitudes, and abilities are always pivotal by the condition may also make a return factors in determining vocational success, to work more difficult. Effective rehabil- the time required to carry out treatment itation that enables individuals to func- recommendations related to the condition tion effectively in their job often involves may make completing a full day at work the interdisciplinary efforts of many types virtually impossible. Interventions to improve antipsy- chotic medication adherence: Review of recent lit- Ben-Shlomo, Y. Journal of Clinical Psychopharmacology, What are the determinants of quality of life in 23(4), 389–399. Archives of Phys- rehabilitation counseling: Making the philosoph- ical Medicine and Rehabilitation, 83(2), 229–235. Effective patient education: A guide Journal of Consulting Clinical Psychology, 69, to increased compliance. Archives of Disease in awaiting lung transplant: Cystic fibrosis versus Childhood, 83(2), 104–110. Life satisfaction after trau- tered approach to sexuality in the face of life-lim- matic brain injury. Patient satisfaction with care and of Research and Personality, 34, 357–379. Neuropsychological sequelae in a series of patients with end-stage cystic fibro- Leplege, A. Moving beyond the illness: Factors con- ic illness and disability: A conceptual framework. Coping strate- gies as predictors and mediators of disability-relat- Cusack, L. Perceptions of body image: ed variables and psychosocial adaptation: An Implications for the workplace. Disability pliance in patients with chronic disease: Issues in Rehabilitation, 24(4), 185–195. The psycho- ence to antidepressants: A systematic review of logical effects of a skin disease. International clas- issues of women with physical disabilities: The sification of impairments, disabilities, and handicaps: continuing gender debate. Rehabilitation A manual of classification relating to the consequences Counseling Bulletin, 46(4), 224–233. A social psychol- Assessment of psychological factors associated ogy approach to measuring vocational rehabilita- with adherence to medication regimens among tion intervention effectiveness. American Journal of Promoting the importance of individual percep- Psychiatry, 159(10), 1653–1664.
The severity of injury depends on the tem- sumption) in common and are muscle spasms 6 letters order skelaxin 400 mg on-line, thus muscle relaxant 114 buy 400mg skelaxin overnight delivery, thought of as com- perature to which the tissue is heated and how long the prising a physiological process muscle relaxant vecuronium discount 400 mg skelaxin free shipping. A com- monly used rule is that a patient’s fluid and calorie needs are Upper limit increased 13% above normal for each 1 C of fever. The profound effect of temperature on biochemical re- Temperature action rates is illustrated by the sluggishness of a reptile regulation Heatstroke, that comes out of its burrow in the morning chill and be- seriously impaired brain lesions comes active only after being warmed by the sun. Homeotherms avoid such a dependence of metabolic rate Temperature on environmental temperature by regulating their internal Fever and regulation exercise body temperatures within a narrow range. A drawback of effective in homeothermy is that, in most homeotherms, certain vital fever and Usual range processes cannot function at low levels of body tempera- health of normal at rest ture that poikilotherms tolerate easily. For example, ship- wreck victims immersed in cold water die of respiratory or circulatory failure (through disruption of the electrical ac- tivity of the brainstem or heart) at body temperatures of Temperature regulation about 25 C, even though such a temperature produces no impaired direct tissue injury and fish thrive in the same water. BODY TEMPERATURES AND HEAT TRANSFER Temperature IN THE BODY regulation lost The body is divided into a warm internal core and a cooler Lower limit outer shell (Fig. Temperature regulation and exposure to heat and outermost layer, the skin. Springfield, cm thick, but in a subject conserving heat in a cold envi- IL: CC Thomas, 1948. CHAPTER 29 The Regulation of Body Temperature 529 Thermal Conductivities and Rates TABLE 29. In this way, these un- derlying tissues, which in the heat were part of the body FIGURE 29. Since the temperatures of the surface and in the trunk and head, the core includes a greater or lesser the thickness of the shell depend on environmental temperature, amount of more superficial tissue—mostly skeletal muscle— the shell is thicker in the cold and thinner in the heat. Because the shell lies between the core and the environ- ment, all heat leaving the body core, except heat lost The internal body temperature that is regulated is the tem- through the respiratory tract, must pass through the shell perature of the vital organs inside the head and trunk, before being given up to the environment. Thus, the shell which, together with a variable amount of other tissue, insulates the core from the environment. We, therefore, need to Changes in skin blood flow, which directly affect core-to- consider heat transfer within the body, especially heat skin heat transfer by convection, also indirectly affect core- transfer (1) from major sites of heat production to the rest to-skin heat transfer by conduction by changing the thick- of the body, and (2) from the core to the skin. In a cool subject, the subcutaneous fat transported within the body by two means: conduction layer contributes to the insulation value of the shell because through the tissues and convection by the blood, a process the fat layer increases the thickness of the shell and because in which flowing blood carries heat from warmer tissues to fat has a conductivity about 0. Thus, fat is a correspondingly better Heat flow by conduction varies directly with the ther- insulator. In a warm subject, however, the shell is relatively mal conductivity of the tissues, the change in temperature thin, and provides little insulation. Furthermore, a warm over the distance the heat travels, and the area (perpendi- subject’s skin blood flow is high, so heat flow from the core cular to the direction of heat flow) through which the to the skin is dominated by convection. It varies inversely with the distance the heat stances the subcutaneous fat layer, which affects conduc- must travel. Heat flow by convection depends on the rate of blood flow and the temperature difference between the tissue and Core Temperature Is Close to the blood supplying the tissue. Because the vessels of the mi- Central Blood Temperature crovasculature have thin walls and, collectively, a large total surface area, the blood comes to the temperature of the sur- Core temperature varies slightly from one site to another rounding tissue before it reaches the capillaries. Changes in depending on such local factors as metabolic rate, blood skin blood flow in a cool environment change the thickness supply, and the temperatures of neighboring tissues. When skin blood flow is reduced in the cold, the ever, temperatures at different places in the core are all affected skin becomes cooler, and the underlying tissues— close to the temperature of the central blood and tend to 530 PART VIII TEMPERATURE REGULATION AND EXERCISE PHYSIOLOGY change together. Infrared ear thermometers are convenient perature, although not strictly correct, is a useful approxi- and widely used in the clinic, but temperatures of the tym- mation. The effects of heavy exercise and fever are familiar; varia- Skin Temperature Is Important in Heat tion among individuals and such factors as time of day Exchange and Thermoregulatory Control (Fig. Temperature- vironmental factors such as air temperature, air move- sensitive neurons and nerve endings in the abdominal vis- ment, and thermal radiation.
Platelet progenitors may be used in patients with tively treated by infusion of specific precursors of the de- one of the many forms of inborn or acquired thrombocy- fective cells spasms under ribs purchase genuine skelaxin on-line, a process termed hematotherapy spasms after stroke buy skelaxin us. In addition muscle relaxant jaw pain buy 400mg skelaxin mastercard, this emerging therapeutic approach cal bone marrow transplant, the entire hematopoietic may soon be enhanced by genetic engineering. In this system (and, consequently, the immune system) of the re- process, new or modified genes are inserted into the grow- cipient is ablated and restored with cells from the donor. For ex- this situation, the most primitive stem cells of the immune ample, a patient may be unable to mount an appropriate or hematopoietic system are eliminated and replaced. In immune response because of the lack of a specific enzyme situations such as AIDS, thrombocytopenia, certain ane- secreted by healthy leukocytes. Stem cells of these pa- mias, and genetic immunodeficiency, however, only spe- tients may be modified in culture to eliminate this defect cific committed progenitor cells of the hematopoietic or and infused back into the patient. We may soon be able to re- hold and generate sufficient progeny, the patient’s im- place these and keep the healthy portion of the patient’s mune defect may be reversed, resulting in a cure of a once hematopoietic system intact. In recent years, much interest has focused on the isola- By far, the major clinical use of stem cells to date has tion, identification, and propagation of the stem cells of been to restore the hematopoietic system of patients various tissues. Hematopoietic stem cells have recently treated with radiation or chemotherapy for cancer. Less been grown in culture and may soon be used for thera- frequently, hematopoietic stem cells have been used to peutic purposes. Hematopoietic stem cells are either com- augment the defective immune system of patients born mitted or pluripotent. New uses of stem cells appear to be generate a specific lineage of cells or are capable of gener- on the horizon. In recent years, several groups have an- ating further developed stem cells that can commit to de- nounced the successful isolation and culture of primitive, velopment along any one of several lineages. Pluripotent nonhematopoietic stem cells from human embryos and stem cells are needed to reconstitute hematopoiesis after fetal tissue. In addition, current reports indicate that the complete disruption that occurs during whole-body ir- these primitive stem cells, cells that can be induced to radiation or after the infusion of chemotherapeutic agents differentiate into any type of cell in the body, can be suc- to treat leukemia and solid tumors. Stem cells could be potentially used nated, resulting in low circulating levels. Although phar- for the regeneration and reconstruction of all types of maceutical progress has resulted in extended survival for damaged tissues. It may be possible References to support patients by periodic infusions of T cell precur- Aldhous P. Nature sors, generated in efficient bioreactors from the patient’s 2000;408:897–898. Mayo eled by specific cytokines that direct the stem cells to Clin Health Lett 2000;18:1–3. Stem cell therapy and gene cells used to initiate the culture would be obtained from transfer for regeneration. Patients would receive an infusion whenever destroy migratory brain tumor cells while also providing a their T cell counts plummeted, protecting them against in- means of repairing tumor-associated damage? In addition to AIDS, hematotherapy holds promise for Spangrude GJ, Cooper DD. Paradigm shifts in stem-cell bi- several other diseases and conditions as well.
Copyright 2006, Interstate Municipal Gas Agency. IMGA notices will be found posted on the IMGA Downloads page. For problems or questions regarding this Web site contact brubenacker@imga.org.
